2006 Albert Lasker Clinical Medical Research Award

Development of cognitive therapy - theory and practice

The 2006 Albert Lasker Award for Clinical Medical Research honors a scientist who transformed the understanding and treatment of a wide range of psychiatric conditions. By realizing that unrealistic negative self-perceptions foster such disturbances and then teaching patients to identify and challenge these distorted thoughts, Aaron T. Beck developed the theory and practice of cognitive therapy. He then subjected this strategy — which defied conventional Freudian principles — to unprecedented rigorous tests. In so doing, he demonstrated its effectiveness and established a new standard for the field of psychotherapy.

Cognitive therapy has proven as effective as medication in alleviating depression and even more effective in reducing relapse and recurrence. Beck and his trainees at the University of Pennsylvania have adapted cognitive therapy to a wide range of other psychiatric disorders. Its power derives in part from the fact that patients assume an active role in their recovery; as a result, they carry tools away from the therapist's office with which they can handle subsequent experiences that threaten their emotional well-being. In addition to conceiving cognitive therapy and showing that it works, Beck devised a number of simple yet sophisticated instruments for assessing the severity of psychiatric symptoms. These tools include the Beck Depression Inventory, Beck Cognitive Insight Scale, and Beck Suicide Intent Scale. They have helped researchers make seminal additions to our understanding of various psychiatric problems and improved suicide classification, assessment, prediction, and prevention. By discovering a previously unrecognized aspect of many mental illnesses and inventing a therapy based on his observations, Beck has made a huge impact on untold numbers of people, relieving immeasurable amounts of suffering.

Illuminating thoughts. Freudian psychoanalytic theory dominated the field of psychiatry until Aaron T. Beck devised cognitive therapy, a treatment that focuses on the conscious rather than the unconscious. In Beck's approach, the therapist and patient together identify the automatic thoughts that cause the patient's emotional and psychological distress. They then work toward challenging this distorted way of thinking. ["The Pleasure Principle," by René Magritte: C 2006. Herscovici, Brussels/ARS, New York]

Different ways of thinking

In 1956, Aaron T. Beck finished his training as a Freudian psychoanalyst, attracted to the field by its promise to improve people's lives. In discovering unknown continents of the mind, the ideology went, psychoanalysis offered unprecedented possibilities by helping individuals overcome the unconscious drives and desires that thwart their sense of well-being and ability to function. Many psychiatrists were skeptical about this method because its impact had not been documented scientifically. In the late 1950s, Beck decided to perform studies to establish its effectiveness. Instead of confirming the tenets of psychoanalytic theory, he showed that this approach omits a crucial root of psychological suffering.

Depression plagued the majority of Beck's patients, so he focused on that illness. According to Freud, depression arises from unconscious — and unacceptable — anger toward another person. Instead of expressing this hostility outwardly, depressed people direct it toward themselves. Psychoanalytic theory predicted that this rage manifests itself in dreams. Beck found, however, that depressed patients don't dream about anger; they dream about loss and personal inadequacy.

Perplexed at the apparent failure of the conventional theory to pass this fundamental test, Beck revised his proposal and subjected it to additional tests. Repeatedly, his observations refuted his hypotheses. Beck gradually discovered that depressed patients in their conscious lives hold the same view of themselves as that expressed in their dreams: They feel like losers.

While probing and developing these ideas, he realized that people seized by depression often have exaggerated and bleak 'automatic thoughts' that trigger uncomfortable feelings. For example, self-criticism, without preceding anger, can prompt feelings of sadness or loneliness. Instead of discarding this observation that contradicted psychoanalytic theory, Beck grabbed onto it. He proposed that these internal messages foster patients' problems. The distorted view grips them, warping their self-perceptions, deflating their hopes and expectations, and making suicide seem like a reasonable escape from unrelenting pain.

These realizations and ideas opened up a previously unexplored inner realm and provided the framework for the theory of cognitive therapy. As people enter depression, they filter out positive information about themselves and amplify negative information, Beck speculated. Patients view themselves as defective and helpless; their future seems hopeless and their lives seem full of insurmountable problems.

These ideas reformulated the core problem in depression: It does not arise from unconscious drives and defenses, as psychoanalytic theory held, but from unduly negative beliefs and bias against oneself. Beck had uncovered a major cause of depression — and one that had been overlooked by the major theoretical perspectives of the time. Neither Freudian therapy nor the other major therapy of the day — behavior therapy, which posited that psychological disturbances resulted from outside forces and could best be resolved by changing the external environment — put stock in the notion that a patient's beliefs, thoughts, or expectations generate distress.

By 1961, Beck had abandoned psychoanalysis. Instead, he was zeroing in on particular instances in which patients felt bad and asking what thoughts immediately preceded the uncomfortable emotion. He then coaxed patients to apply the scientific method to their beliefs, urging them to examine the evidence. A woman who felt worthless might reveal that, immediately before her mood plummeted, she had thought, "I'm a bad mother." Beck would probe further to unearth the apparent basis for this internal statement, and then ask questions such as, "When siblings from other families fight with one other, does that mean their parents are doing a bad job?" "If the neighbor children went to school without their boots or forgot their lunches, would you condemn their mother?" With this approach, he prodded patients to assess the accuracy of what they were telling themselves. As they began to gain objectivity, their self-images started to improve, and their problems cleared up. He noticed significant changes almost immediately. After 10-12 weekly sessions, patients' symptoms had usually resolved. Beck had developed a short-term therapy for depression.

By 1964, Beck had laid out the foundations of his theory and practice. These revolutionary ideas encountered resistance, but he went on to demonstrate that his new cognitive therapy altered patients' feelings and behaviors quickly and in an enduring way.

Better than drugs

In the 1970s, Beck conducted the first rigorous study of any type of 'talk therapy'. He pitted cognitive therapy against the best antidepressant drug at the time — imipramine — in a prospective, randomized, controlled clinical trial designed to test how effectively these two approaches ameliorated symptoms of a particular disorder: depression. In this head-to-head comparison, cognitive therapy outperformed the drug after a treatment period of up to 12 weeks. Furthermore, the benefits persisted a year later. In contrast, the effectiveness of psychoanalysis, whose normal course is years, has not been proven, as it has not been subjected to this type of randomized, controlled study. This work established cognitive therapy as a powerful clinical intervention and set a new standard for evaluating the effectiveness of any kind of psychotherapy. Numerous studies since then have reaffirmed that the approach is equal or better at combating depression than are antidepressant drugs; furthermore, it is better at preventing relapse.

Beck and his trainees spent the next three decades adapting cognitive therapy to treat additional problems—such as anxiety disorders, panic disorders, and social phobias—and testing its utility. As part of this enterprise, he developed powerful instruments with which to measure the severity of symptoms associated with various psychiatric illnesses. Prior to this work, a dearth of techniques for measuring the severity of such disturbances hampered psychiatric research.

Saving lives

Among his major achievements, Beck has made dramatic advances in helping people with suicidal urges, in part by providing a classification and assessment scheme for predicting suicidal behavior. Beck recognized that the feeling of hopelessness is crucial for evaluating suicidal patients. He developed a "hopelessness scale" — a series of simple questions — that measure the degree to which an individual feels as if current problems are solvable. Beck and his colleagues have tracked patients for more than 30 years, and have found that this tool can indicate the likelihood of a person to commit suicide, particularly for individuals at high risk. In a seven-year study of 1958 outpatients, the test pinpointed 16 of the 17 people who killed themselves during that period; individuals who scored above a particular hopelessness rating were eleven times more likely to commit suicide than were the low scorers. Thus, the risk of hopeless patients eventually dying as a result of suicide was approximately the same as that of heavy smokers dying from lung cancer.

In 2005, Beck and his colleagues published a paper that demonstrated the effectiveness of cognitive therapy for suicidal individuals. 120 patients who were evaluated at an emergency room immediately after a suicide attempt received support and referrals from a caseworker; half of these patients underwent 10 sessions of cognitive therapy in addition. Participants in the cognitive-therapy group were almost 50 percent less likely than non-participants to attempt suicide during the 18-month follow-up period.

In the United States, more than 30,000 people die each year from suicide, making it the eleventh leading cause of death; among people between the ages of 15 and 24, it is the third biggest killer. Worldwide, suicide is among the three leading causes of death among individuals between 15 and 44 years old. Because Beck has invented a simple tool with which to predict future suicidal behavior and a therapy that dramatically reduces attempts, his work has enormous potential for slashing those figures. Furthermore, it could tremendously benefit especially high-risk populations, such as those on college campuses.

Soothing mental distress around the globe

Cognitive therapy has become a mainstay in the practices of many mental health practitioners worldwide. The American Psychiatric Association's guidelines state that cognitive behavioral therapy (an offshoot of cognitive therapy) is one of the two best-documented psychotherapies for treating major depression. Health systems in Europe recommend it for treating a number of common psychiatric disorders. Inspired by the success of cognitive therapy in curing depression, the United Kingdom's Department of Health is launching a $6.8 million pilot program aimed at significantly increasing access to 'talk' therapies. If results are favorable, the government will expand the program and expects to save millions of dollars by helping people with mild to moderate depression get back to work and off disability benefits.

Beck's development of cognitive therapy and his discovery that it effectively treats serious mental illnesses has major public health significance. Countless individuals owe their sense of well-being — and their lives — to Beck's work.

Award presentation by Huda Zoghbi

By the end of the 19th century, the discoveries of medical pioneers such as Louis Pasteur and Robert Koch had led us into the era of modern medicine. They understood disease to be caused by some physical disturbance rather than evil spirits or an imbalance of the humours. This was not just an advance for those suffering from illnesses that wiped out whole townships, but it also spelled progress for the insane. Neurologists began to show that brain diseases such as syphilis or tumors could produce bizarre changes in personality. Even if treatments were slow to come, the insane could be viewed with more compassion, as suffering actual brain damage rather than demonic possession.

But what of those cases, where a physical disturbance could not be found? Even worse, what about those cases where a physical problem seemed impossible? Take, for example, that prototypical 19th-century illness, hysteria. Hysterical patients displayed puzzling symptoms, such as a numbness of the hand that stopped abruptly at the wrist, which did not make sense with the wiring of the nervous system. Enter Sigmund Freud.

Freud was trained as a neurologist and studied with the great French neurologist Jean-Martin Charcot. Charcot attributed hysterical symptoms to some undefined inflammation of the nerves — this was very much a physical model of disease. Freud made the monumental leap that neuroses could be caused by psychic distress. This incredible notion that feelings and ideas could produce illness created a new category of disorders defined as mental illness that is distinct from diseases that damage the brain. In the process, Freud described the unconscious, a powerful inner world of drives and conflicts that could explain everything from slips of the tongue to hysterical paralysis. Freud's general concepts of neurosis and the unconscious were firmly embedded in both medical and popular culture. But by the 1950s, some of the specifics of his theory, such as the infamous idea that all neurosis was rooted in sexual repression, were wearing thin. While medicine had been reaping the benefits of the scientific method, no one had put psychoanalysis to the test. Yet that was the dominant form of therapy. Clearly, psychiatry was heading for a crisis. Enter a young psychoanalyst named Aaron Timothy Beck.

One afternoon, Beck was treating a young woman who was having difficulties with men. As she lay on the couch describing her sexual encounters, Beck asked her: "How does talking about this make you feel?" Now, as a psychoanalyst he was not supposed to ask such a question, but rather let the patient's unconscious bubble to the surface. Nevertheless, he followed his curiosity, and the patient replied that she felt anxious. Beck proposed that she felt anxious because she expected disapproval of her sexual desires. Breaking another cardinal rule of psychoanalysis, he asked the patient to sit up and face him, so she could see from his expression that there was no disapproval. At this point, the patient broke with expectations and confessed: "No, I don't think you're disapproving; I think I'm boring you." This was the Eureka moment for Beck. He realized that if patients were concerned with what their therapists think, there was little use in waiting for unconscious thoughts to bubble up. He abandoned probing for unconscious sexual conflicts and began focusing on the patterns of thoughts that made his patients depressed or anxious. Thus was born a new type of treatment to become known as cognitive therapy.

Like Charcot and Freud, Beck started his career as a neurologist. During his neurology residency he was required to train for six months in psychiatry, which he initially thought was a distraction. But he quickly became fascinated by psychoanalysis as a tool to probe the workings of the mind. Beck switched fields and became a Freudian psychoanalyst. Many scientists were skeptical about the effectiveness of psychoanalysis, so Beck set out to confirm the tenets of the psychoanalytic theory through research. His initial focus was on depression.

According to psychoanalytic theory, depression can be caused by unconscious anger towards another person. Because such outward hostility is unacceptable, depressed patients direct the anger toward themselves (which results in low self-esteem). Since Freud argued that dreams are the "Royal Road to the Unconscious," Beck decided to search for hostility in the dreams of depressed patients. What struck him most was not hostility but that depressed patients saw themselves in their dreams exactly as they did in their waking hours: as hopeless and helpless. He also noticed that his depressed patients had "automatic thoughts" that colored innocuous events with dark meaning. These negative interpretations in many cases could precipitate a depression.

For example, take a man whose wife leaves in the morning without giving him the customary kiss. He might fear that she does not love him anymore and begin accumulating other pieces of neutral data to support his dismal conclusion, becoming more and more distraught. A cognitive therapist will ask the patient to recount the morning conversation he had with his wife. During this process he recalls that she told him she was in a hurry to make an early meeting at the office. Beck helped his patients identify these subtle but powerful automatic thoughts, question the unhelpful and destructive ones and replace them with more realistic thoughts. Thus, the tenet of cognitive therapy is that our cognition (how we think) determines our feelings and behavior.

In contrast to the years of undirected exploration of the unconscious in psychoanalysis, cognitive therapy focuses on the preconscious that is not quite in awareness but is accessible. Within weeks, this therapy provides patients with the skills to recognize negative, self-defeating thoughts when they occur and to step back from them, effecting a slow but steady improvement in mood and function. In 1977, Beck conducted the first rigorous clinical trial of any type of psychotherapy in depression. He compared the effectiveness of cognitive therapy to imipramine (the best antidepressant at the time). Twelve weeks of cognitive therapy proved superior to pharmacotherapy, and its benefits persisted a year later. These findings established cognitive therapy as a powerful and effective intervention for depression and set a standard for evaluating the clinical benefits of any type of psychotherapy.

When Beck recognized the need for sensitive rating instruments, he developed the Beck Depression Inventory (which became one of the most widely used measures of depression symptoms in the world). Beck and his trainees went on to adapt cognitive therapy for a variety of psychiatric disorders and showed that it is effective therapy for generalized anxiety, panic disorders, post-traumatic stress disorder, phobias, and bulimia.

Cognitive therapy has proven to be beneficial in so many illnesses that departments of psychiatry are now required to teach cognitive therapy to their residents. The National Institute of Clinical Excellence in England now states that cognitive behavior therapy should be available as a therapeutic option for all mental disorders. The Labour Government made a commitment to train 10,000 therapists so that at least 1 million psychiatric patients can access this treatment. This unique initiative is predicted to save the government 10 billion pounds each year and to make the society healthier and happier.

One in five adults will suffer from a diagnosable mental disorder in a given year in the United States. Thirty thousand people will commit suicide each year — that's twice the number of homicides in the States. Mental illness, including suicide, accounts for 15% of the burden of disease in established market economies. This is more than the disease burden caused by ALL cancers. At least 60 million Americans suffer from depression or anxiety disorders. There is no doubt that formal training of more individuals in cognitive therapy will significantly decrease the burden of psychiatric diseases.

Aaron Beck is often described as a "giant" by psychiatrists, but inside this giant there is a kind and creative man who is always searching for the best ways to help people. His greatest passions are psychiatry and science. Although he plays tennis and enjoys reading history books, most of his time is spent reading scientific journals or thinking about how to better diagnose and treat psychiatric disorders. Thus it is not surprising that at the age of 85 years he received two NIH grants to support his research. The medical community is fortunate that Aaron Beck took on the challenging psychiatric disorders and showed us that the mind is plastic and adaptable if we let the brain's cognitive power take control.

Aaron T. Beck

Acceptance remarks, 2006 Lasker Awards Ceremony

Thank you, Dr. Zoghbi, for a wonderful introduction and the Awards Committee for this unique honor.

As the Great Bard once suggested: "All of life is a drama — or the illusion of such." Fortunately, the main players in the First Act of my professional drama are here today. My drama started with a (surprising, to me) observation — which Dr. Zoghbi described as my "Eureka experience." At that time, there was regrettably no professional with whom I could discuss this apparent "revelation." Fortunately, I was able to sharemy ideas with my wife, Phyllis, en route to becoming a judge. She acknowledged that it had logic — but what is the evidence?

I also described this notion to my teenage daughter, Judith (who is now a notable psychologist in her own right), who assured me, "It sounds reasonable, Dad." The question, of course, raised by Phyllis, was, "What is the evidence?"

This posed a problem: Since I had no training in research methodology or statistics, how could I get the evidence?

Fortunately, my good friend Marvin Stein (later distinguished for his work in neuro-immunology) came to my rescue and helped me design a study and prepare a proposal for a research grant to test my theory. With the grant funding in hand, I then embarked on a number of studies of depression and later suicide that did provide the evidence for the theory.

In the Second Act in the drama, I developed a therapy on the basis of the theory — later named cognitive therapy. At that time, one of my residents, John Rush (now a highly recognized researcher), said, "You've got a new therapy, Tim, but nobody will believe it until you conduct a clinical trial." I protested that these trials are "backbreaking," and there was no way I could undertake this. But John persevered. I trained other residents in the therapy and he conducted the trial. In time, the study showed positive results in comparison with the antidepressant medication imipramine, the gold standard of the time.

I was very fortunate to attract other talented postdoctoral researchers, and adaptations of cognitive therapy were developed (especially in the United Kingdom) for almost all of the common psychiatric disorders, including schizophrenia.

The climax of the Third Act is being played out today. This award is not only a singular honor for me, but also, by implication, to my group of former mentees. It also recognizes that clinical psychological research can meet the rigorous standards of scientific investigation and make an important contribution to the health of the greater community. For my role in that, I am proud and grateful. I thank you all for sharing this climactic moment with me.